Provider Demographics
NPI:1316945694
Name:FIDONE, JEFFREY W (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:W
Last Name:FIDONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15210 COUNTY ROAD 164
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-571-1985
Mailing Address - Fax:
Practice Address - Street 1:15210 COUNTY ROAD 164
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-571-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31842207RC0200X
TXH6215207RC0200X, 207RP1001X
IN01080093A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102165102Medicaid
TX290005858OtherRR MC
TX81G479Medicare ID - Type Unspecified
TX102165102Medicaid